Not much headway

Doctors voice concerns on continuing dangers of concussions in NFL

When Buffalo Bills quarterback Drew Bledsoe decided to play against the New York Giants Nov. 30 after suffering a concussion the week before, he wasn't using his head.

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"He sent out the wrong message," said Dr. Robert Cantu, chief of neurosurgery at Emerson Hospital in Concord and medical director of the National Center for Catastrophic Sports Injury Research in Chapel Hill, N.C. "Everybody's in unanimous agreement that you should not have an individual play in a contact sport if he is still [having] post-concussion symptoms. There isn't a shred of evidence that condones playing."

During the week Bledsoe suffered dizziness, nausea, and headaches. He said he still felt "fuzzy" after practicing two days before the game.

"I'm angry that the message they are conveying by playing is that it's OK to play with concussion symptoms," said Cantu. "That is absolutely wrong, and it's really wrong for the scholar [college and high school] athletes."

The Bills said Bledsoe passed all neurological tests, including National Football League baseline testing. "The pros are paid incredible amounts of money to do what they do, and the quarterback is the team leader, but the brain is a bit unique compared to the knees and back," said Cantu. "There's just no question you should not be playing with a brain injury."

Bledsoe's wife urged him not to play. "She's right," said the doctor. "She probably knows the literature better than he does."

"That doesn't mean that you can't play Russian roulette and get away with it, but it's not the correct thing to do even at professional levels."

Cantu's research is included in a recent article in the Journal of the American Medical Association that said players who return to play too soon run a greater risk of suffering another head injury.

Against the Giants, Bledsoe suffered a helmet-to-helmet hit that momentarily knocked him unconscious in the third quarter of a 24-7 win. He was removed from the game after complaining of being dizzy and seeing "yellow." He returned to play in the next week's 17-6 victory against the Jets.

There are 300,000 sport-related concussions annually in the United States, according to the Centers for Disease Control and Prevention. The chance of permanent damage increases with repeated head injury, according to the JAMA report.

"He's risking two things," said Cantu. "If he gets another concussion, that the symptoms will be exponentially worse and last exponentially longer than they would otherwise because you've got an injured brain that's been re-injured before it's totally recovered. That's the most likely thing he risks. So instead of having a concussion that you can shake the symptoms off in a week, which is the usual thing, those symptoms may last months. Down the road he's risking cumulative effects of concussion, which may mean that his ability to withstand future concussions may be compromised."

No laughing matter

Concussions have forced the retirement of quarterbacks Troy Aikman, Steve Young, Chris Miller, and Stan Humphries, but those playing other positions are more likely to be concussed, such as linebackers, offensive linemen, and defensive backs.

The old joke is that the acronym NFL stands for "Not For Long" if players linger in the trainer's room nursing injuries. But now a lot of retired athletes are no longer laughing. A recent study says NFL players who suffer multiple concussions are far more likely to suffer clinical depression later in life.

"It's the first time we've been able to link some long-term consequences to recurrent concussions," said Keven Guskiewicz, research director of the Center For the Study of Retired Athletes at the University of North Carolina. "Once you've had three or more concussions you're really pre-disposed to having a bout with depression at some point in your life."

The recent study analyzed responses by 2,488 retired NFL players with an average age of 58 and with 6.7 years of NFL experience. The results were surprising. More than one in 10 retired players (11 percent) said they had been diagnosed with clinical depression. Nearly nine out of 10 (87 percent) still suffer from depression, and nearly half (46 percent) are currently being treated with anti-depressants.

Concussions are just now being recognized as a silent epidemic in sports. "We have a terrifying health emergency here that no one seems to respond to. It's one more indication that the danger of concussion needs serious action," said Leigh Steinberg, an agent who has represented a slew of stars, including the concussion-prone Aikman. The former Cowboy is not alone, however. "Athletes by nature are in various stages of denial," said Steinberg, who has organized seminars on the subject. "They'd like me to shut up."

Steinberg advocates better equipment and having neurologists on the sideline of every NFL game. "The old concept of holding up fingers doesn't cut it," he said. "The study of the brain is the last frontier."

Bill Curry played 10 years in the NFL with Green Bay, Baltimore, Houston, and Los Angeles. He has a sense of humor. He likes to tell people that he was on the cover of Sports Illustrated twice. That's true. Unfortunately it was his rear end, with either Bart Starr or Johnny Unitas hovering over him, awaiting the snap from center. Curry still misses Johnny U, who toward the end of his life couldn't hold a fork or toothbrush with his famous right hand because of injuries he sustained playing football. And Curry becomes serious when he talks about the damage of concussions. "It's very important to understand what we are doing with our bodies," he said. "It could literally save lives."

Curry, 60, now an ESPN analyst and Center for the Study of Retired Athletes board member, attends NFL reunions with mixed emotions. "There's this joy of seeing the guys mixed with the horror of those who are not there," he said. "The most unsettling thing is to see the sharpest, most dignified men who cannot function, who have lost their faculties. It just breaks your heart. Some are really suffering."

Curry remembered his early days as a center and linebacker for the Packers playing in a game in 1965 against the Steelers. "I got a concussion and they took me to the locker room," he said. "I didn't know who I was or where I was. They had to get my wife and let her into the locker room. She was the first woman in a Packers locker room. I was out of it.

"So on Monday morning they have a team meeting to look at film. [Coach Vince] Lombardi announced, `I want Curry and [Ray] Nitschke out on the practice field with [offensive line] coach Wietecha.' Everyone knew Ray Nitschke had the toughest forearm in football. It was a two-man practice. Nitschke smashed into me for 15 minutes, and I had really tough headaches."

Curry toughed it out. "It dawned on me later," he said, "that was my physical, to see if I could stick it out. This is not an indictment of Lombardi. You can say that was evil or wrong, but that's how it was in the league. We didn't even think about it."

"We'd get dinged or get our bell rung once a game," he said. "Linemen get hit every play. I don't know, I might have had 100 concussions. I played at 235-240. Now the big guys literally weigh 100 pounds more and run faster. Imagine the G-forces and the collisions."

Despite all the pain, Curry said it was worth it. "If I could turn the clock back, I'd get the barbells and the protein drinks and I'd report this July," he said. "It's nothing rational. It's not the money. I would've played 'til I dropped. I loved it that much. But I've got some buddies in bad shape. We need to help them."

Important study

Dr. Julian Bailes, who founded the Center for the Study of Retired Athletes and serves as its medical director, said it is the first time that a large group of athletes who have repeatedly been concussed has been studied. He acknowledged that depression "is a hard disease to study. People have a lot of reasons to be depressed. Many football players are used to acclaim and success during their playing days. But the study found a strong correlation between depression and concussion exposure."

The study, entitled "Recurrent Sport-Related Concussion Linked to Clinical Depression" and partially funded by the NFL Players Association, said retired players with more than five concussions had nearly a three-fold risk of depression and those with three to four concussions had double the risk of clinical depression compared to those retired players that had no concussions.

Of the NFL players studied, 61 percent reported at least one concussion during their career, 24 percent sustained three or more, and 12 percent five or more. Loss of consciousness was reported by 54 percent of NFL retirees. The study said 71 percent of the players who suffered concussions returned to play in the same game. "That's kind of alarming," said Guskiewicz, who has studied concussions for a decade. "If you've lost consciousness, suffered memory loss, or are still symptomatic, you should never be returned to play the same day."

Part of the problem is that concussions are for the most part invisible. "It's amazing," said Guskiewicz. "The problem is we can't visibly witness the damage that's occurred, so you kind of question a guy. Is he really hurt?"

To make his point, he showed a grotesque photograph of a player whose foot has been twisted in the opposite direction. "This guy, with his dislocated ankle, is not going into play, not tomorrow, not the next day, not for several months," he said. "But with the head injury, it's just so subjective. We can't see the swelling, there's no redness, there's no signs of inflammation. It's not like a knee injury that can be iced."

Most people don't even know what a concussion is, Guskiewicz said.

"A concussion is a blow to the head that results in some temporary alteration of mental status," he said. "For years people thought that to sustain a concussion, you had to lose consciousness. That's simply not true.

"The brain sits inside the skull like a big ice cube in a glass of water. At impact the helmet keeps the tissue from tearing but the ricocheting big ice cube hits the glass and turns. No helmet can stop that."

At North Carolina, Guskiewicz has legendary basketball coach Dean Smith's old office, which overlooks Carmichael Auditorium's wood floor, where a young Michael Jordan learned to fly in the early '80s.

Soon creaky-legged NFL retirees will be coming to UNC to be tested. They will be asked to stand on the $59,500 NeuroCom SMART Balance Master, which feels like being in a small earthquake but measures the sensory and volunteer motor control of balance. They also will be tested on motion analysis systems that gauge flexibility, and also will be subjected to neuropysch tests.

"They're very interested," said Guskiewicz. "They are a really unique group. That's the amazing thing. Almost 90 percent of our sample has said they want to come here to be studied. They are battered, they've paid a price for fame. They want to help the guys out there now."

Previous Center for the Study of Retired Athlete studies have found that linemen particularly have not aged well. They have higher incidences of hypertension and cardiovascular disease. Fifty-two percent have a greater risk of dying from heart disease than the general public, and 50 percent of the linemen live with osteoarthritis. It is a vicious cycle -- they can't exercise and they haven't changed their eating habits.

A bad image?

Guskiewicz worries that the image of beefed up NFL linemen is sending the wrong message to the collegiate and high school levels. "It tells them that they've got to have the advantage of weight or they won't make it to the big time," he said. "So more kids are put at risk."

Guskiewicz hopes the center's research trickles down to high school kids and Pop Warner leagues. Approximately 1.2 million Americans play football annually and it is estimated that between 10 and 20 percent may sustain concussions every year, according to the American Association of Neurological Surgeons.

"Parents think, `That can't happen to me, my kid's not getting hit as hard as Troy Aikman,' " said Guskiewicz. "But it can it happen to them. Even a slight injury can be catastrophic if the recovery from the first one wasn't complete."

Most people are familiar with the case of Korey Stringer, the Minnesota Vikings lineman who died of heat stroke at training camp in August 2001. But few know about the death of 17-year-old Costa Mesa high school linebacker Matthew Colby, who died in 2001 of second-impact concussion syndrome.

Colby apparently complained of severe headaches for two weeks following a Sept. 15 game in which he said he had a concussion. He did not take part in practice drills but said he wanted to play in a game against Westminster High School Sept. 29. The team trainer relied on a note from a family doctor before allowing Colby to return to play, school officials said, according to a brief article in the Orange County Register.

During that game, Colby wobbled off the field and collapsed on the sideline. He was taken off life support two days later. The coroner ruled he died of brain swelling and bleeding caused by more than one blow to the head over a period of days.

"It's a very sad story," said Gusciewicz. "I've gotten to know the family. There are a lot of family physicians who don't manage concussions properly. This is the perfect example."

"It's a problem with the axons [of the brain] breaking down," he said. "If they don't get sufficient time to heal properly, they deteriorate to the point where they can't send the proper message from one axon to the next axon. It's like a series of extension cords. You're plugging them all together and one of them has a fray. There's electricity escaping from it, so the brain loses regulation of its blood supply and there can be catastrophic injury from a second blow to the head."

Future studies will include an in-depth study of possible links between concussions and Alzheimer's disease. A review of the latest data from NFL retirees shows a higher ratio of mild cognitive impairment, which is a precursor to Alzheimer's. Thirty-three NFL retirees in the latest survey have Alzheimer's disease. "Three of those 33 retirees developed Alzheimer's disease before 60, which is very early relative to the normal population [in which only 2 percent develop the disease before 60]," said Guskiewicz. "The NFL players are being diagnosed with it 10 years earlier than the general population. But the question is, is it because they have better access to medical care and so they have access to a neurologist, where the average Joe doesn't?"

Steinberg says the early Alzheimer's data is just one more indication of a health crisis. "It's one thing to know you'll have aches and pains playing with your kids when you're 50, it's quite another not to be able to identify those children," he said.

The NHL started mandatory baseline neurologic testing in 1997 to determine an athlete's cognitive skills before the season. Players who suffer concussions are re-tested twice, within 24 hours after the injury and then within five days, to gauge damage. The testing includes memory, motor speed, mental processing speed, and attention. But the NFL has yet to implement a mandatory neurologic testing program, although some clubs do it on their own.

"We don't have a league-wide rule, it's a team doctor issue," said NFL spokesman Greg Aiello.

"The NFL is crazy," said Guskiewicz. "Sometimes I'm not sure they want to know the answer."